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King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
SKILL CHECKLISTS FOR MIDTERM EXAM 1
1. Performing Hand Hygiene Using Soap And Water (Handwashing)
2. Using Personal Protective Equipment
3. Putting On Sterile Gloves And Removing Soiled Gloves
4. Assessing Body Temperature
5. Assessing a Peripheral Pulse by Palpation
6. Assessing Respirations
7. Assessing Blood Pressure
8. Assessing Height and Weight
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Name ___________________________________ Date __________________
Instructor/Evaluator: ________________________________
FORMULATING NURSING CARE PLAN
Assessment
Subjective
Objective
Nursing Diagnosis
Planning
Implementation 1.
2.
3.
4.
5.
6.
7.
Evaluation
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Skill 2.1 PERFORMING HAND HYGIENE USING SOAP AND WATER
(HANDWASHING)
Handwashing, as opposed to Hand Hygiene with an Alcohol based rub is required when:
When hands are visibly dirty
When hands are visibly soiled with (or in contact with) blood or other body fluids
Before eating or after using the restroom
If exposure to certain microorganisms, such as those causing Anthrax or Clostridium deficile
Equipment:
Antimicrobial soap
Paper towels
Oil free lotion (optional )
Goal: The hands will be free of visible soiling and transient microorganisms will be eliminated
PROCEDURE Rationale
1. Gather the necessary supplies
2. Stand in front of the sink. Do not allow your
clothing to touch the sink during the washing
procedure.
The sink is considered contaminated. Clothing may
carry organisms from place to place
3. Remove jewelry, if possible, and secure in a safe
place. A plain wedding band may remain in place.
Removal of jewelry facilitates cleansing.
Microorganisms may accumulate in settings of
jewelries
4. Turn on water and adjust force. Regulate the
temperature until the water is warm.
Water splashed from the contaminated sink will
contaminate clothing. Warm water is more
comfortable and is less likely to open pores and
remove oils from the skin
5. Wet the hands and wrist area. Keep hands lower
than elbows to allow water to flow toward fingertips.
Water should flow from the cleaner area toward the
more contaminated area. Hands are more
contaminated than forearms.
6. Use about 1 teaspoon liquid soap from dispenser or
rinse bar of soap and lather thoroughly.. Cover all
areas of hands with the soap product.
Rinsing of soap before and after use removes the
lather, which may contain microorganisms.
7. With firm rubbing and circular motions, wash the
palms and backs of the hands, each finger, the areas
between the fingers, and the knuckles, wrists, and
forearms.
Friction helps to loosen dirt and microorganisms that
can lodge between the fingers , in skin crevices
between the knuckles, on the palms and back of the
hands, and on the wrists and forearms
8. Wash at least 1 inch above area of contamination. If
hands are not visibly soiled, wash to 1 inch above
the wrists.
To prevent the spread of microorganisms from the
hands to the forearms and wrists
9. Continue this friction motion for at least 15 seconds.
10. Use fingernails of the opposite hand or a clean
orangewood stick to clean under fingernails.
Area under the nails has high microorganism count,
and organisms may remain under the nails
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
11. Rinse thoroughly with water flowing toward
fingertips.
Running water rinses microorganisms and dirt into
the sink
12. Pat hands dry with a paper towel, beginning with
the fingers and moving upward toward forearms,
and discard it immediately.
To prevent chapping. Dry hands first because they
are considered the cleanest and least contaminated
area
13. Use another clean towel to turn off the faucet.. Protects the clean hands from contact with the soiled
surface.
14. Discard towel immediately without touching other
clean hand
To prevent contamination
15. Use oil-free lotion on hands if desired. Oil free lotion helps keep the skin soft and prevents
chapping
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Name ___________________________________ Date __________________
Instructor/Evaluator: ________________________________ Score ____ /10 marks
Skill 2.1 PERFORMING HAND HYGIENE USING SOAP AND WATER
(HANDWASHING)
Legend:
2 Performed Correctly
1 - Performed with Assistance
0 - Not performed
Goal: The hands will be free of visible soiling and transient microorganisms will be eliminated.
Equipment:
Antimicrobial soap
Paper towels
Oil free lotion (optional )
Per
form
ed
Co
rrec
tly
Per
form
ed
wit
h a
ssis
tan
ce
No
t P
erfo
rmed
PROCEDURE
Comments
1. Gather the necessary supplies
2. Stand in front of the sink. Do not allow your clothing to touch the
sink during the washing procedure.
3. Remove jewelry, if possible, and secure in a safe place. A plain
wedding band may remain in place.
4. Turn on water and adjust force. Regulate the temperature until the
water is warm.
5. Wet the hands and wrist area. Keep hands lower than elbows to
allow water to flow toward fingertips.
6. Use about 1 teaspoon liquid soap from dispenser or rinse bar of
soap and lather thoroughly..
7. Cover all areas of hands with the soap product.
8. With firm rubbing and circular motions, wash the palms and
backs of the hands, each finger, the areas between the fingers, and
the knuckles, wrists, and forearms.
9. Wash at least 1 inch above area of contamination. If hands are not
visibly soiled, wash to 1 inch above the wrists.
10. Continue this friction motion for at least 15 seconds.
11. Use fingernails of the opposite hand or a clean orangewood stick
to clean under fingernails.
12. Rinse thoroughly with water flowing toward fingertips.
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
13. Pat hands dry with a paper towel, beginning with the fingers and
moving upward toward forearms, and discard it immediately.
14. Use another clean towel to turn off the faucet..
15. Discard towel immediately without touching other clean hand
16. Use oil-free lotion on hands if desired.
Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for
Taylor's Clinical Nursing Skills: A Nursing Process Approach, 3rd edition, by Pamela Lynn and Marilee
LeBon.
Scoring and Evaluation
Range Interpretation
24.25 – 32 Excellent
16.50 – 24.24 Satisfactory
8.75 – 16.49 Fair
1.00 -8.74 Poor
For Major Examination:
Actual Score X 10 marks
Perfect Score
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Skill 2.2 Using Personal Protective Equipment Equipment:
Gloves
Mask
Gown (disposable)
Protective eyewear
Goal: The transmission of microorganisms is prevented.
PROCEDURE Rationale
1. Check medical record and nursing plan of care for
type of precautions and review precautions in
infection control manual.
Mode of transmission of organism determines
type of precautions required
2. Plan nursing activities before entering patient’s
room.
Organization facilitates performance of task
and adherence to precautions
3. Perform hand hygiene. Hand hygiene prevents the spread of
microorganism
4. Provide instruction about precautions to patient,
family members, and visitors.
Explanation encourages cooperation of patient
and family and reduces apprehensions about
precaution procedures
5. Put on gown, gloves, mask, and protective eyewear,
based on the type of exposure anticipated and
category of isolation precautions.
Use of PPE interrupts chain of infection and
protects patient and nurse.
a. Put on the gown, with the opening in the back.
Tie gown securely at neck and waist.
Gown should protect entire uniform. Gown
should fully cover the torso from the neck to the
knees, arms to the end of wrists and wrap around
the back
b. Put on the mask or respirator over your nose,
mouth, and chin. Secure ties or elastic bands
at the middle of the head and neck
Masks protect nurse or patient from droplet
nuclei and large particle aerosols. A mask must
fit securely to provide protection
c. Put on goggles. Place over eyes and adjust to
fit. Alternately, a face shield could be used to
take the place of the mask and goggles.
Eye wear protects mucous membranes in the
eyes from splashes. Must fit securely to provide
protection
d. Put on clean disposable gloves. Extend gloves
to cover the cuffs of the gown.
Gloves protect hands and wrists from
microorganisms
6. Identify the patient. Explain the procedure to the
patient. Continue with patient care as appropriate.
Patient identification validates the correct patient
and the correct procedure. Discussion and
explanation helps allay anxiety and prepare the
patient for what to expect.
Removing PPE
7. Remove PPE: Except for respirator, remove PPE at
the doorway or in an anteroom.
Remove respirator after leaving the patient room
and closing door.
Proper removal prevents contact with and spread
of microorganism
Prevents contact with airborne microorganism
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
a. If impervious gown has been tied in front of
the body at the waistline, untie waist strings
before removing gloves.
Outside front of equipment is considered
contaminated. The inside, outside back, ties on
the head and back are considered clean which are
areas of PPE which are unlikely to have been in
contact with infectious organism . Front of
gown, including waist strings are contaminated.
If tied in front of the body, the ties must be
untied before removing the gloves
b. Grasp the outside of one glove with the
opposite gloved hand and peel off, turning the
glove inside out as you pull it off.
Hold the removed glove in the remaining
gloved hand.
c. Slide fingers of ungloved hand under the
remaining glove at the wrist, taking care not
to touch the outer surface of the glove
Ungloved hand is clean and should not touch the
contaminated areas
d. Peel off the glove over the first glove,
containing the one glove inside the other.
Discard in appropriate container.
Proper disposal prevents transmission of
microorganisms
e. To remove the goggles or face shield: Handle
by the headband or ear pieces. Lift away from
the face. Place in designated receptacle for
reprocessing or in an appropriate waste
container
Outside of goggles or face shield is considered
contaminated . Do not touch. Handling by
headband or earpieces and lifting away from
face prevents transmission of microorganism
f. To remove gown: Unfasten ties, if at the neck
and back.
Allow the gown to fall away from
shoulders.
Touching only the inside of the gown,
pull away from the torso. Keeping hands
on the inner surface of the gown, pull
from arms.
Turn gown inside out.
Fold or roll into a bundle and discard.
Gown front and sleeves are contaminated.
Touching only the inside of the gown and
pulling it away from the torso prevents
transmission of microorganism. Proper disposal
prevents transmission of microorganism.
g. To remove mask or respirator: Grasp the
neck ties or elastic, then top ties or elastic
and remove.
Take care to avoid touching front of
mask or respirator.
Discard in waste container.
Front of mask or respirator is contaminated. Do
not touch prevents transmission of
microorganism.
8. Perform hand hygiene immediately after removing
all PPE.
Hand hygiene prevents spread of
microorganisms.
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Name ___________________________________ Date __________________
Instructor/Evaluator: ________________________________ Score ____ /10 marks
Skill 2.2 Using Personal Protective Equipment
Legend:
2 Performed Correctly
1 - Performed with Assistance
0 - Not performed
Goal: The transmission of microorganisms is prevented.
Equipment:
Gloves
Mask
Gown (disposable)
Protective eyewear
Perfo
rm
ed
Correctl
y
Perfo
rm
ed
wit
h
ass
ista
nce
Not
Perfo
rm
ed
PROCEDURE
Comments
1. Check medical record and nursing plan of care for type of
precautions and review precautions in infection control manual.
2. Plan nursing activities before entering patient’s room.
3. Perform hand hygiene.
4. Provide instruction about precautions to patient, family
members, and visitors.
5. Put on gown, gloves, mask, and protective eyewear, based on
the type of exposure anticipated and category of isolation
precautions.
a. Put on the gown, with the opening in the back. Tie gown
securely at neck and waist.
b. Put on the mask or respirator over your nose, mouth, and
chin. Secure ties or elastic bands at the middle of the head
and neck
c. Put on goggles. Place over eyes and adjust to fit.
Alternately, a face shield could be used to take the place of
the mask and goggles.
d. Put on clean disposable gloves. Extend gloves to cover the
cuffs of the gown.
6. Identify the patient. Explain the procedure to the patient.
Continue with patient care as appropriate.
Removing PPE
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
7. Remove PPE: Except for respirator, remove PPE at the
doorway or in an anteroom. Remove respirator after leaving
the patient room and closing door.
a. If impervious gown has been tied in front of the body at the
waistline, untie waist strings before removing gloves.
b. Grasp the outside of one glove with the opposite gloved
hand and peel off, turning the glove inside out as you pull
it off.
Hold the removed glove in the remaining gloved hand.
c. Slide fingers of ungloved hand under the remaining glove at
the wrist, taking care not to touch the outer surface of the
glove
d. Peel off the glove over the first glove, containing the one
glove inside the other. Discard in appropriate container.
e. To remove the goggles or face shield: Handle by the
headband or ear pieces. Lift away from the face. Place in
designated receptacle for reprocessing or in an appropriate
waste container
f. To remove gown: Unfasten ties, if at the neck and back.
Allow the gown to fall away from shoulders.
Touching only the inside of the gown, pull away from
the torso. Keeping hands on the inner surface of the
gown, pull from arms.
Turn gown inside out.
Fold or roll into a bundle and discard.
g. To remove mask or respirator: Grasp the neck ties or
elastic, then top ties or elastic and remove.
Take care to avoid touching front of mask or
respirator.
Discard in waste container.
8. Perform hand hygiene immediately after removing all PPE. Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical
Nursing Skills: A Nursing Process Approach, 3rd edition, by Pamela Lynn and Marilee LeBon
Scoring and Evaluation
Range Interpretation
37.75 - 50 Excellent
25.5 – 37.74 Satisfactory
13.25 – 25.49 Fair
1.00 -13.24 Poor
For Major Examination:
Actual Score X 10 marks
Perfect Score
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Skill 2.3 PUTTING ON STERILE GLOVES AND REMOVING SOILED GLOVES
Equipment:
Goal: The gloves are applied and removed without contamination.
PROCEDURE Rationale
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient. Explain the procedure to the
patient.
3. Check that the sterile glove package is dry and
unopened.
Moisture contaminates a sterile package.
4. Also note expiration date, making sure that the date is
still valid.
Expiration date indicates the period that the
package remains sterile
5. Place sterile glove package on clean, dry surface at or
above your waist.
Moisture could contaminate a sterile gloves.
Any sterile object held below the waist is
considered contaminated.
6. Open the outside wrapper by carefully peeling the top
layer back.
This maintains sterility of the gloves in inner
packet
7. Remove inner package, handling only the outside of
it.
Allows for ease of glove application
8. Place the inner package on the work surface with the
side labeled ‘cuff end’ closest to the body.
9. Carefully open the inner package. Fold open the top
flap, then the bottom and sides.
10. Take care not to touch the inner surface of the
package or the gloves.
The inner surface of the package is considered
sterile. The outer 1 inch border of the inner
package is considered contaminated. The
sterile gloves are exposed with the cuff end
closest to the nurse
11. With the thumb and forefinger of the nondominant
hand, grasp the folded cuff of the glove for the
dominant hand, touching only the exposed inside of
the glove.
Unsterile hand touches only inside of gloves.
Outside remains sterile
12. Keeping the hands above the waistline, lift and hold
the glove up and off the inner package with fingers
down.
13. Be careful it does not touch any unsterile object. Glove is contaminated if it touches any
unsterile items
14. Carefully insert dominant hand palm up into glove
and pull glove on. Leave the cuff folded until the
opposite hand is gloved.
Attempting to turn upward with unsterile
hand may result in contamination of sterile
gloves
15. Hold the thumb of the gloved hand outward. Lift it
from the wrapper, taking care not to touch anything
with the gloves or hands.
Thumb is less likely to become contaminated
if held outward. Sterile surface touching
sterile surface prevents contamination.
Sterile Gloves
PPE
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
16. Carefully insert nondominant hand into glove.
17. Pull the glove on, taking care that the skin does not
touch any of the outer surfaces of the gloves.
Sterile surface touching sterile surface
prevents contamination.
18. Slide the fingers of one hand under the cuff of the
other and fully extend the cuff down the arm,
touching only the sterile outside of the glove.
Sterile surface touching sterile surface
prevents contamination.
19. Repeat for the remaining hand.
20. Adjust gloves on both hands if necessary, touching
only sterile areas with other sterile areas.
Sterile surface touching sterile surface
prevents contamination.
21. Continue with procedure as indicated.
Removing Soiled Gloves
22. Use dominant hand to grasp the opposite glove near
cuff end on the outside exposed area.
Contaminated area does not come in contact
with hands or wrists
23. Remove it by pulling it off, inverting it as it is pulled,
keeping the contaminated area on the inside. Hold the
removed glove in the remaining gloved hand.
24. Slide fingers of ungloved hand between the remaining
glove and the wrist. Take care to avoid touching the
outside surface of the glove
Contaminated area does not come in contact
with hands or wrists
25. Remove it by pulling it off, inverting it as it is pulled,
keeping the contaminated area on the inside, and
securing the first glove inside the second.
26. Discard gloves in appropriate container. Remove
additional PPE, if used.
Proper disposal and removal of PPE reduces
the risk for infection transmission and
contamination of other items. Hand hygiene
prevents the spread of microorganism
27. Perform hand hygiene.
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Name ___________________________________ Date __________________
Instructor/Evaluator: ________________________________ Score ____ /10 marks
Skill 2.3 PUTTING ON STERILE GLOVES AND REMOVING
SOILED GLOVES
Legend:
2 Performed Correctly
1 - Performed with Assistance
0 - Not performed
Goal: The gloves are applied and removed without contamination.
Equipment:
Per
form
ed
Co
rrec
tly
Per
form
ed w
ith
ass
ista
nce
No
t P
erfo
rmed
PROCEDURE
Comments
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient. Explain the procedure to the patient.
3. Check that the sterile glove package is dry and unopened.
4. Also note expiration date, making sure that the date is still
valid.
5. Place sterile glove package on clean, dry surface at or
above your waist.
6. Open the outside wrapper by carefully peeling the top layer
back.
7. Remove inner package, handling only the outside of it.
8. Place the inner package on the work surface with the side
labeled ‘cuff end’ closest to the body.
9. Carefully open the inner package. Fold open the top flap,
then the bottom and sides.
10. Take care not to touch the inner surface of the package or
the gloves.
11. With the thumb and forefinger of the nondominant hand,
grasp the folded cuff of the glove for the dominant hand,
touching only the exposed inside of the glove.
12. Keeping the hands above the waistline, lift and hold the
glove up and off the inner package with fingers down.
13. Be careful it does not touch any unsterile object.
Sterile Gloves
PPE
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
14. Carefully insert dominant hand palm up into glove and pull
glove on. Leave the cuff folded until the opposite hand is
gloved.
15. Hold the thumb of the gloved hand outward.
16. Lift it from the wrapper, taking care not to touch anything
with the gloves or hands.
17. Carefully insert nondominant hand into glove.
18. Pull the glove on, taking care that the skin does not touch
any of the outer surfaces of the gloves.
19. Slide the fingers of one hand under the cuff of the other
and fully extend the cuff down the arm, touching only the
sterile outside of the glove.
20. Repeat for the remaining hand.
21. Adjust gloves on both hands if necessary, touching only
sterile areas with other sterile areas.
22. Continue with procedure as indicated.
Removing Soiled Gloves
23. Use dominant hand to grasp the opposite glove near cuff
end on the outside exposed area.
24. Remove it by pulling it off, inverting it as it is pulled,
keeping the contaminated area on the inside.
25. Hold the removed glove in the remaining gloved hand.
26. Slide fingers of ungloved hand between the remaining
glove and the wrist. Take care to avoid touching the
outside surface of the glove
27. Remove it by pulling it off, inverting it as it is pulled,
keeping the contaminated area on the inside, and securing
the first glove inside the second.
28. Discard gloves in appropriate container. Remove additional
PPE, if used.
29. Perform hand hygiene. Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical
Nursing Skills: A Nursing Process Approach, 3rd edition, by Pamela Lynn and Marilee LeBon.
Scoring and Evaluation
Range Interpretation
43.75 - 58 Excellent
29.5 – 37.74 Satisfactory
15.25 – 25.49 Fair
1.00 -15.24 Poor
For Major Examination:
Actual Score X 10 marks
Perfect Score
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Skill 3.1 Assessing Body Temperature
Equipment:
Digital, glass or electronic thermometer
Disposable probe covers
Non sterile gloves
PPE
Toilet tissue
Pencil or pen, paper or flow sheet
Alcohol swab
Goal: The patient’s temperature is assessed accurately without injury and the patient experiences only
minimal discomfort.
PROCEDURE Rationale
1. Check medical order or nursing care plan for
frequency of measurement and route. More
frequent temperature measurement may be
appropriate based on nursing judgment.
Assessment and measurement of vital signs at
appropriate intervals provide important data about
the patient’s health status
2. Perform hand hygiene and put on PPE, if
indicated.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
transmission precaution
3. Identify the patient. Ensures that the patient receives the intervention
and helps prevent errors
4. Close curtains around bed and close the door to
the room, if possible.
This ensures the patient’s privacy . Explanation
relieves anxiety and facilitates cooperation.
5. Discuss the procedure with patient and assess
the patient’s ability to assist with the procedure.
Dialogue encourages patient participation
6. Assemble equipment to the bedside stand or
overbed table within reach
Organization facilitates performance of task
7. Ensure the electronic or digital thermometer is
in working condition.
Improperly functioning thermometer may not give an
accurate reading
8. Put on gloves, if appropriate or indicated. Gloves prevent contact with blood and body fluids.
Gloves usually are not required for an oral , axillary
or tympanic temperature measurement unless contact
with blood or body fluids is anticipated. Gloves
should be worn for rectal temperature measurement.
9. Select the appropriate site based on previous
assessment data.
This ensures safety and accuracy of measurement
10. Follow the steps as outlined below for the
appropriate type of thermometer.
11. When measurement is completed, remove
gloves, if worn. Remove additional PPE, if
used.
Reduces the risk of infection transmission and
contamination of other items.
12. Perform hand hygiene.
Prevents the spread of microorganisms
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Measuring Oral Temperature
1. Remove the electronic unit from the charging
unit, and remove the probe from within the
recording unit.
Electronic unit must be taken into the patient’s room
to assess the patient’s temperature. On some models,
by removing the probe, the machine is already turned
on.
2. Cover thermometer probe with disposable
probe cover and slide it on until it snaps into
place.
Using a cover prevents contamination of the Probe
3. Place the probe beneath the patient’s tongue
in the posterior sublingual pocket. Ask the
patient to close his or her lips around the
probe.
When the probe rests deep in the posterior
sublingual pocket, it is in contact with the blood
vessels lying close to the surface
4. Continue to hold the probe until you hear a
beep. Note the temperature reading.
If left unsupported, the weight of the probe tends to
pull it away from the correct location . The signal
indicates that the measurement is completed. \the
electronic thermometer provides a digital display of
the measured temperature.
5. Remove the probe from the patient’s mouth.
Dispose of the probe cover by holding the
probe over an appropriate receptacle and
pressing the probe release button.
Disposing of the probe ensures that it will not be
reused accidentally on another patient.
6. Return the thermometer probe to the storage
place within the unit. Return the electronic unit
to the charging unit, if appropriate.
The thermometer needs to be recharged for future
use. If necessary, the thermometer should stay on the
charger so that it is ready to use at all times.
Measuring a Tympanic Membrane Temperature
1. If necessary, push the “on” button and wait for
the “ready” signal on the unit.
For proper function. The thermometer must be turned
on and warmed up
2. Slide disposable cover onto the tympanic
probe.
3. Insert the probe snugly into the external ear
using gentle but firm pressure, angling the
thermometer toward the patient’s jaw line.
Pull pinna up and back to straighten the ear
canal in an adult.
If the probe is not inserted correctly, the patient’s
temperature may be noted as lower than normal
4. Activate the unit by pushing the trigger button.
The reading is immediate (usually within 2
seconds). Note the reading.
5. Discard the probe cover in an appropriate
receptacle by pushing the probe-release button
or use rim of cover to remove from probe
Disposing of the probe ensures that it will not be
reused accidentally on another patient.
6. Replace the thermometer in its charger, if
necessary.
The thermometer needs to be recharged for future
use. If necessary, the thermometer should stay on the
charger so that it is ready to use at all times.
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Measuring Rectal Temperature
1. Adjust the bed to a comfortable working height,
usually elbow height of the care giver (VISN 8 Patient
Safety Center, 2009).
Prevents back and muscle strain
2. Put on nonsterile gloves.
3. Assist the patient to a side-lying position. Pull back
the covers sufficiently to expose only the buttocks.
Side-lying position allows the nurse to
visualize the buttocks. Exposing only the
buttocks keeps the patient warm and
maintains his or her dignity
4. Remove the rectal probe from within the recording
unit of the electronic thermometer. Cover the probe
with a disposable probe cover and slide it into place
until it snaps in place.
5. Lubricate about 1 inch of the probe with a water-
soluble lubricant.
Lubrication reduces friction and facilitates
insertion minimizing the risk of irritation or
injury to the rectal mucous membranes
6. Reassure the patient. Separate the buttocks until the
anal sphincter is clearly visible.
If not placed directly into the anal opening ,
the thermometer probe may injure adjacent
tissue or cause discomfort.
7. Insert the thermometer probe into the anus about 1.5
inches in an adult or 1 inch in a child.
Depth of insertion must be adjusted based on
the patient’s age. Rectal temperatures are not
normally taken in an infant , but may be
indicated.
8. Hold the probe in place until you hear a beep, then
carefully remove the probe. Note the temperature
reading on the display.
If left unsupported, movement in the probe of
the rectum could cause injury or discomfort.
9. Dispose of the probe cover by holding the probe over
an appropriate waste receptacle and pressing the
release button
10. Using toilet tissue, wipe the anus of any feces or
excess lubricant. Dispose of the toilet tissue.
Wiping promotes cleanliness
11. Remove gloves and discard them.
12. Cover the patient and help him or her to a position of
comfort.
Ensures patient comfort
13. Place the bed in the lowest position; elevate rails as
needed.
This action provides for patient’s safety
14. Return the thermometer to the charging unit. The thermometer needs to be recharged for
future use
Assessing Axillary Temperature
1. Move the patient’s clothing to expose only the axilla. Exposing only the axilla keeps the patient
warm and maintains his or her dignity
2. Remove the probe from the recording unit of the
electronic thermometer. Place a disposable probe
cover on by sliding it on and snapping it securely.
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
3. Place the end of the probe in the center of the axilla.
Have the patient bring the arm down and close to the
body.
The deepest area of the axilla provides the
most accurate measurement surrounding the
bulb with the skin surface provides a more
reliable measurement
4. Hold the probe in place until you hear a beep, and
then carefully remove the probe. Note the temperature
reading.
5. Cover the patient and help him or her to a position of
comfort.
6. Dispose of the probe cover by holding the probe over
an appropriate waste receptacle and pushing the
release button.
7. Place the bed in the lowest position and elevate rails,
as needed. Leave the patient clean and comfortable.
8. Return the electronic thermometer to the charging
unit.
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Name ___________________________________________ Date __________________
Instructor/Evaluator: _______________________________ Score ____ /10 marks
Skill 3.1 Assessing Body Temperature
Legend:
2 Performed Correctly
1 - Performed with Assistance
0 - Not performed
Goal: The patient’s temperature is assessed accurately without injury and the patient experiences only
minimal discomfort.
Equipment:
Digital, glass or electronic thermometer
Disposable probe covers
Non sterile gloves
PPE
Toilet tissue
Pencil or pen, paper or flow sheet
Alcohol swab
Per
form
ed
Co
rrec
tly
Per
form
ed w
ith
ass
ista
nce
No
t P
erfo
rmed
PROCEDURE
Comments
1. Check medical order or nursing care plan for frequency of
measurement and route. More frequent temperature measurement may
be appropriate based on nursing judgment.
2. Bring necessary equipment to the bedside stand or overbed table.
3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
5. Close curtains around bed and close the door to the room, if possible.
6. Discuss the procedure with patient and assess the patient’s ability to
assist with the procedure.
7. Ensure the electronic or digital thermometer is in working condition.
8. Put on gloves, if appropriate or indicated.
9. Select the appropriate site based on previous assessment data.
10. Follow the steps as outlined below for the appropriate type of
thermometer.
11. When measurement is completed, remove gloves, if worn. Remove
additional PPE, if used.
12. Perform hand hygiene.
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Assessing Oral Temperature
13. Remove the electronic unit from the charging unit, and remove the
probe from within the recording unit.
14. Cover thermometer probe with disposable probe cover and slide it on
until it snaps into place.
15. Place the probe beneath the patient’s tongue in the posterior
sublingual pocket. Ask the patient to close his or her lips around the
probe.
16. Continue to hold the probe until you hear a beep. Note the
temperature reading.
17. Remove the probe from the patient’s mouth. Dispose of the probe
cover by holding the probe over an appropriate receptacle and
pressing the probe release button.
18. Return the thermometer probe to the storage place within the unit.
Return the electronic unit to the charging unit, if appropriate.
Measuring a Tympanic Membrane Temperature
19. If necessary, push the “on” button and wait for the “ready” signal on
the unit.
20. Slide disposable cover onto the tympanic probe.
21. Insert the probe snugly into the external ear using gentle but firm
pressure, angling the thermometer toward the patient’s jaw line.
Pull pinna up and back to straighten the ear canal in an adult.
22. Activate the unit by pushing the trigger button. The reading is
immediate (usually within 2 seconds). Note the reading.
23. Discard the probe cover in an appropriate receptacle by pushing the
probe-release button or use rim of cover to remove from probe
24. Replace the thermometer in its charger, if necessary.
Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for
Taylor's Clinical Nursing Skills: A Nursing Process Approach, 3rd edition, by Pamela Lynn and Marilee
LeBon.
Scoring and Evaluation
Range Interpretation
36.25 - 48 Excellent
24.5 – 36.24 Satisfactory
12.75 – 24.49 Fair
1.00 -12.74 Poor
For Major Examination:
Actual Score X 10 marks
Perfect Score
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Skill 3.2 Assessing a Peripheral Pulse by Palpation
Equipment
Watch with a second hand
Pencil or pen, paper or flow sheet
Non sterile gloves
PPE
Alcohol swab
Goal: The patient’s pulse is assessed accurately without injury and the patient experiences only minimal
discomfort.
PROCEDURE Rationale
1. Check medical order or nursing care plan for
frequency of pulse assessment. More frequent
pulse measurement maybe appropriate based
on nursing judgment.
Assessment and measurement of vital signs at
appropriate intervals provide important data about
the patient’s health status
2. Perform hand hygiene and put on PPE, if
indicated.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
transmission precaution
3. Identify the patient. Ensures that the patient receives the intervention
and helps prevent errors
4. Close curtains around bed and close the door
to the room, if possible.
This ensures the patient’s privacy .
5. Discuss the procedure with patient and assess
the patient’s ability to assist with the
procedure.
Explanation relieves anxiety and facilitates
cooperation.
6. Put on gloves, as appropriate. Gloves usually are not usually worn to obtain a
pulse measurement unless contact with blood or
body fluids is anticipated.
7. Select the appropriate peripheral site based on
assessment data.
This ensures safety and accuracy of measurement
8. Move the patient’s clothing to expose only the
site chosen.
9. Place your first, second, and third fingers over
the artery.
10. Lightly compress the artery so pulsations can
be felt and counted.
The sensitive fingertips can feel the pulsation of the
artery
11. Using a watch with a second hand, count the
number of pulsations felt for 30 seconds.
Multiply this number by 2 to calculate the
rate for 1 minute.
If the rate, rhythm, or amplitude of the
pulse is abnormal in any way, palpate
and count the pulse for 1 minute.
Ensures accuracy of measurement and assessment
12. Note the rhythm and amplitude of the pulse. Provides additional assessment data regarding the
patient’s cardiovascular status
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
13. When measurement is completed, remove
gloves, if worn.
14. Cover the patient and help him or her to a
position of comfort.
15. Remove additional PPE, if used. Perform hand
hygiene.
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Name ___________________________________ Date __________________
Instructor/Evaluator: ________________________________ Score _______/ 10 marks
Skill 3.2 Assessing a Peripheral Pulse by Palpation
Legend:
2 Performed Correctly
1 - Performed with Assistance
0 - Not performed
Goal: The patient’s pulse is assessed accurately without injury and the patient experiences only minimal
discomfort.
Equipment
Watch with a second hand
Pencil or pen, paper or flow sheet
Non sterile gloves
PPE
Alcohol swab
Per
form
ed
Co
rrec
tly
Per
form
ed w
ith
ass
ista
nce
No
t P
erfo
rmed
PROCEDURE
Comments
1. Check medical order or nursing care plan for frequency of pulse
assessment. More frequent pulse measurement maybe
appropriate based on nursing judgment.
2. Perform hand hygiene and put on PPE, if indicated.
3. Identify the patient.
4. Close curtains around bed and close the door to the room, if
possible.
5. Discuss the procedure with patient and assess the patient’s
ability to assist with the procedure.
6. Put on gloves, as appropriate.
7. Select the appropriate peripheral site based on assessment data.
8. Move the patient’s clothing to expose only the site chosen.
9. Place your first, second, and third fingers over the artery.
10. Lightly compress the artery so pulsations can be felt and
counted.
11. Using a watch with a second hand, count the number of
pulsations felt for 30 seconds.
Multiply this number by 2 to calculate the rate for 1 minute.
If the rate, rhythm, or amplitude of the pulse is abnormal
in any way, palpate and count the pulse for 1 minute.
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
12. Note the rhythm and amplitude of the pulse.
13. When measurement is completed, remove gloves, if worn.
14. Cover the patient and help him or her to a position of comfort.
15. Remove additional PPE, if used. Perform hand hygiene.
Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for
Taylor's Clinical Nursing Skills: A Nursing Process Approach, 3rd edition, by Pamela Lynn and Marilee
LeBon.
Scoring and Evaluation
Range Interpretation
22.75 – 30 .00 Excellent
15.5 – 22.74 Satisfactory
8.25 – 15.49 Fair
1.00 -8.24 Poor
For Major Examination:
Actual Score X 10 marks
Perfect Score
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Skill 3.3 Assessing Respiration
Equipment:
Goal: The patient’s respirations are assessed accurately without injury and the patient experiences only
minimal discomfort.
PROCEDURE Rationale
1. While your fingers are still in place for the pulse
measurement, after counting the pulse rate, observe
the patient’s respirations.
The patient may alter the rate of respiration
if he or she is aware they are being
counted.
2. Note the rise and fall of the patient’s chest. A complete cycle of inspiration and an
expiration composes one respiration
3. Using a watch with a second hand, count the number of
respirations for 30 seconds. Multiply this number by 2
to calculate the respiratory rate per minute.
Sufficient time is necessary to observe the
rate, depth, and other characteristics
4. If respirations are abnormal in any way, count the
respirations for at least 1 full minute.
Increased time allows the detection of
unequal timing between respirations
5. Note the depth and rhythm of the respirations. Provides additional assessment data
regarding the patient’s respiratory status
6. When measurement is completed, remove gloves, if
worn.
7. Cover the patient and help him or her to a position of
comfort.
8. Remove additional PPE, if used. Perform hand hygiene.
Watch with a second hand
Pencil or pen, paper or flow sheet
PPE
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Name ___________________________________ Date __________________
Instructor/Evaluator: ________________________________ Score _____/ 10 marks
Skill 3.3 Assessing Respiration
Legend:
2 Performed Correctly
1 - Performed with Assistance
0 - Not performed
Goal: The patient’s respirations are assessed accurately without injury and the patient experiences only
minimal discomfort.
Equipment:
Perfo
rm
ed
Correctl
y
Perfo
rm
ed
wit
h
ass
ista
nce
Not
Perfo
rm
ed
PROCEDURE
Comments
1. While your fingers are still in place for the pulse measurement,
after counting the pulse rate, observe the patient’s respirations.
2. Note the rise and fall of the patient’s chest.
3. Using a watch with a second hand, count the number of respirations
for 30 seconds. Multiply this number by 2 to calculate the
respiratory rate per minute.
4. If respirations are abnormal in any way, count the respirations for
at least 1 full minute.
5. Note the depth and rhythm of the respirations.
6. When measurement is completed, remove gloves, if worn.
7. Cover the patient and help him or her to a position of comfort.
8. Remove additional PPE, if used. Perform hand hygiene.
Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for
Taylor's Clinical Nursing Skills: A Nursing Process Approach, 3rd edition, by Pamela Lynn and Marilee
LeBon.
Watch with a second hand
Pencil or pen, paper or flow sheet
PPE
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Scoring and Evaluation
Range Interpretation
12.25 – 16 .00 Excellent
8.5 – 12.24 Satisfactory
4.75 – 8.49 Fair
1.00 -4.74 Poor
For Major Examination:
Actual Score X 10 marks
Perfect Score
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Skill 3.4 Assessing Brachial Artery Blood Pressure
Equipment
Stethoscope
Sphygmomanometer
Blood Pressure cuff of appropriate size
Pencil or pen, paper or flow sheet
PPE
Alcohol swab
Goal: The patient’s blood pressure is measured accurately with minimal discomfort to the patient.
PROCEDURE Rationale
1. Check physician’s order or nursing care plan for
frequency of blood pressure measurement. More
frequent measurement may be appropriate based
on nursing judgment.
Provides for patient safety
2. Perform hand hygiene and put on PPE, if
indicated.
3. Identify the patient.
4. Close curtains around bed and close the door to
the room, if possible.
5. Discuss procedure with patient and assess
patient’s ability to assist with the procedure.
Validate that the patient has relaxed for several
minutes.
6. Put on gloves, if appropriate or indicated.
7. Select the appropriate arm for application of the
cuff.
Measurement of Blood pressure may temporarily
impede circulation to the extremity
8. Have the patient assume a comfortable lying or
sitting position with the forearm supported at the
level of the heart and the palm of the hand
upward.
Support the arm yourself or by using
the bedside table.
Have the patient sit back in the chair so
that the chair supports his or her back.
Make sure the patient keeps the legs
uncrossed
This position places the brachial artery on the
inner aspect of the elbow so that bell or
diaphragm of the stethoscope can rest on it
easily.
Sitting position ensures accuracy
The position of the arm can have a major
influence when the blood pressure is
measured;
if the upper arm is below the level of the
atrium , the readings will be too high.
If the arm is above the level of the
atrium , the readings will be too low.
If the back is not supported , the diastolic
pressure maybe elevated falsely
If the legs are crossed, the systolic
pressure maybe elevated falsely.
9. If the measurement is taken in the supine
position, support the arm with a pillow.
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
10. Expose the brachial artery by removing
garments, or move a sleeve, if it is not too tight,
above the area where the cuff will be placed.
Clothing over the artery interferes with the ability
to hear sounds and can cause inaccurate blood
pressure readings. A tight sleeve would cause
congestion of blood and possibly inaccurate
readings.
11. Palpate the location of the brachial artery.
12. Center the bladder of the cuff over the brachial
artery, about midway on the arm, so that the
lower edge of the cuff is about 2.5 to 5 cm (1 to
2 inches) above the inner aspect of the elbow.
Pressure in the cuff applied directly on the artery
provides the most accurate readings . If the cuff
gets in the way of the stethoscope , readings are
likely to be inaccurate .
13. Line the artery marking on the cuff up with the
patient’s brachial artery. The tubing should
extend from the edge of the cuff nearer the
patient’s elbow.
A cuff placed upside down with the tubing toward
the patient’s head may give a false reading .
14. Wrap the cuff around the arm smoothly and
snugly, and fasten it. Do not allow any clothing
to interfere with the proper placement of the
cuff.
A smooth cuff and snug wrapping produce equal
pressure and helps promote an accurate
measurement . A cuff wrapped too loosely results
in an inaccurate reading.
15. Check that the needle on the aneroid gauge is
within the zero mark. If using a mercury
manometer, check to see that the manometer is
in the vertical position and that the mercury is
within the zero level with the gauge at eye level.
If the needle is not in the zero area, the BP reading
may not be accurate. Tilting a mercury
manometer , inaccurate calibration, or improper
height for reading the gauge can lead to errors in
determining the pressure measurements.
Estimating Systolic Pressure
16. Palpate the pulse at the brachial or radial artery
by pressing gently with the fingertips.
Palpation allows for measurement of the
approximate systolic readings.
17. Tighten the screw valve on the air pump. The bladder within the cuff will not inflate with
the valve open.
18. Inflate the cuff while continuing to palpate the
artery. Note the point on the gauge where the
pulse disappears.
The point where the pulse disappears provides an
estimate of the systolic pressure. To identify the
first Korotkoff sound accurately, the cuff must be
inflated to a pressure above the point at which the
pulse can no longer be felt.
19. Deflate the cuff and wait 1 minute. Allowing a brief cause before continuing permits
the blood to refill and circulate through the arm
Obtaining Blood Pressure Measurement
20. Assume a position that is no more than 3 feet
away from the gauge.
A distance of more than 3 feet can interfere with
accurate reading of the numbers on the gauge
21. Place the stethoscope earpieces in your ears.
Direct the earpieces forward into the canal and
not against the ear itself.
Proper placement blocks extraneous noise and
allows sound to travel more clearly
22. Place the bell or diaphragm of the stethoscope
firmly but with as little pressure as possible over
the brachial artery.
Allows more accurate reading. Heavy pressure on
the brachial artery distorts the shape of the artery
and the sound. .
23. Do not allow the stethoscope to touch clothing
or the cuff.
Placing the bell or the diaphragm away from the
clothing and the cuff prevents the noise , which
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
would distract from the sounds made by blood
flowing through the artery
24. Pump the pressure 30 mm Hg above the point at
which the systolic pressure was palpated and
estimated.
Increasing the pressure above the point where the
pulse disappeared ensures the period before
hearing the first sound that corresponds with the
systolic pressure.
25. Open the valve on the manometer and allow air
to escape slowly (allowing the gauge to drop 2
to 3 mm per second).
It prevents misinterpreting phase II sound as
phase I sound
26. Note the point on the gauge at which the first
faint, but clear, sound appears that slowly
increases in intensity. Note this number as the
systolic pressure. Read the pressure to the
closest 2 mm Hg.
Systolic pressure is the point at which the blood in
the artery is first able to force its way through the
vessel at a similar pressure exerted by the air
bladder in the cuff. The first sound is phase I of
Korotkoff sounds.
27. Do not reinflate the cuff once the air is being
released to recheck the systolic pressure reading.
Reinflating the cuff while obtaing the BP is
uncomfortable for the patient and can cause an
inaccurate reading . Reinflatiing the cuff causes
congestion of blood in the lower arm , which
lessens the loudness of Korotkoff sounds .
28. Note the point at which the sound completely
disappears.
The point at which the sound disappears
corresponds to the beginning of phase V
Korotkoff sounds and is generally considered the
diastolic pressure reading.
29. Allow the remaining air to escape quickly.
Repeat any suspicious reading, but wait at least
1 minute. Deflate the cuff completely between
attempts to check the blood pressure.
False readings are likely to occur if there is
congestion of blood in the limb while obtaining
repeated readings
30. When measurement is completed, remove the
cuff. Remove gloves, if worn. Cover the patient
and help him or her to a position of comfort
31. Clean the diaphragm of the stethoscope with the
alcohol wipe. Clean and store the
sphygmomanometer, according to facility
policy.
32. Remove additional PPE, if used. Perform hand
hygiene.
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Name ___________________________________ Date __________________
Instructor/Evaluator: ________________________________ Score ________ / 10 marks
Skill 3.4 Assessing Brachial Artery Blood Pressure
Legend:
2 Performed Correctly
1 - Performed with Assistance
0 - Not performed
Goal: The patient’s blood pressure is measured accurately with minimal discomfort to the patient.
Equipment
Stethoscope
Sphygmomanometer
Blood Pressure cuff of appropriate size
Pencil or pen, paper or flow sheet
PPE
Alcohol swab
Per
form
ed
Co
rrec
tly
Per
form
ed w
ith
ass
ista
nce
No
t P
erfo
rmed
PROCEDURE
Comments
1. Check physician’s order or nursing care plan for frequency of
blood pressure measurement. More frequent measurement
may be appropriate based on nursing judgment.
2. Perform hand hygiene and put on PPE, if indicated.
3. Identify the patient.
4. Close curtains around bed and close the door to the room, if
possible.
5. Discuss procedure with patient and assess patient’s ability to
assist with the procedure. Validate that the patient has
relaxed for several minutes.
6. Put on gloves, if appropriate or indicated.
7. Select the appropriate arm for application of the cuff.
8. Have the patient assume a comfortable lying or sitting
position with the forearm supported at the level of the heart
and the palm of the hand upward.
Support the arm yourself or by using the bedside
table.
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Have the patient sit back in the chair so that the
chair supports his or her back.
Make sure the patient keeps the legs uncrossed
9. If the measurement is taken in the supine position, support
the arm with a pillow.
10. Expose the brachial artery by removing garments, or move a
sleeve, if it is not too tight, above the area where the cuff
will be placed.
11. Palpate the location of the brachial artery.
12. Center the bladder of the cuff over the brachial artery,
about midway on the arm, so that the lower edge of the
cuff is about 2.5 to 5 cm (1 to 2 inches) above the inner
aspect of the elbow.
13. Line the artery marking on the cuff up with the patient’s
brachial artery. The tubing should extend from the edge of
the cuff nearer the patient’s elbow.
14. Wrap the cuff around the arm smoothly and snugly, and
fasten it. Do not allow any clothing to interfere with the
proper placement of the cuff.
15. Check that the needle on the aneroid gauge is within the zero
mark. If using a mercury manometer, check to see that the
manometer is in the vertical position and that the mercury is
within the zero level with the gauge at eye level.
Estimating Systolic Pressure
16. Palpate the pulse at the brachial or radial artery by pressing
gently with the fingertips.
17. Tighten the screw valve on the air pump.
18. Inflate the cuff while continuing to palpate the artery. Note
the point on the gauge where the pulse disappears.
19. Deflate the cuff and wait 1 minute
Obtaining Blood Pressure Measurement
20. Assume a position that is no more than 3 feet away from the
gauge.
21. Place the stethoscope earpieces in your ears. Direct the
earpieces forward into the canal and not against the ear
itself.
22. Place the bell or diaphragm of the stethoscope firmly but
with as little pressure as possible over the brachial artery.
23. Do not allow the stethoscope to touch clothing or the cuff.
24. Pump the pressure 30 mm Hg above the point at which the
systolic pressure was palpated and estimated.
25. Open the valve on the manometer and allow air to escape
slowly (allowing the gauge to drop 2 to 3 mm per second).
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
26. Note the point on the gauge at which the first faint, but
clear, sound appears that slowly increases in intensity.
Note this number as the systolic pressure. Read the
pressure to the closest 2 mm Hg.
27. Do not reinflate the cuff once the air is being released to
recheck the systolic pressure reading.
28. Note the point at which the sound completely disappears.
29. Allow the remaining air to escape quickly. Repeat any
suspicious reading, but wait at least 1 minute. Deflate the
cuff completely between attempts to check the blood
pressure.
30. When measurement is completed, remove the cuff. Remove
gloves, if worn. Cover the patient and help him or her to a
position of comfort
31. Clean the diaphragm of the stethoscope with the alcohol
wipe. Clean and store the sphygmomanometer, according to
facility policy.
32. Remove additional PPE, if used. Perform hand hygiene.
Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for
Taylor's Clinical Nursing Skills: A Nursing Process Approach, 3rd edition, by Pamela Lynn and Marilee
LeBon.
Scoring and Evaluation
Range Interpretation
48..25 – 64 .00 Excellent
32.5 – 48.24 Satisfactory
16.75 – 32.49 Fair
1.00 -16.74 Poor
For Major Examination:
Actual Score X 10 marks
Perfect Score
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Name ___________________________________ Date __________________
Instructor/Evaluator: ________________________________ Score ______/ 10 marks
Skill 3.5 Assessing Height And Weight
Legend:
2 Performed Correctly
1 - Performed with Assistance
0 - Not performed
Goal: The assessment is completed without the patient experiencing anxiety or discomfort,
Per
form
ed
Co
rrec
tly
P
erfo
rmed
wit
h
ass
ista
nce
N
ot
Per
form
ed
PROCEDURE
Comments
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient.
3. Close curtains around bed and the door to the room, if
possible.
4. Explain the purpose of the health examination and what you
are going to do. Answer any questions
5. Have the patient remove shoes and heavy outer clothing.
6. Weigh the patient using a scale
7. Compare the measurement with previous weight
measurements and recommended range for height.
8. With shoes off, and standing erect, measure the patient’s
height using a wall-mounted measuring device or measuring
pole.
9. Compare height and weight with recommended average
weights on a standardized chart.
10. Using the tape measure, measure the patient’s waist
circumference. Place the tape measure snugly around the
patient’s waist at the level of the umbilicus
11. Measure the patient’s temperature, pulse, respirations, blood
pressure, and oxygen saturation.
12. Remove PPE, if used.
13. Perform hand hygiene. Continue with assessments of specific
body systems as appropriate or indicated.
14. Initiate appropriate referral to other healthcare practitioners
for further evaluation as indicated
.
King Saud university NURS 215
College of Nursing FUNDAMENTALS OF NURSING 1st Semester AY 1439-1440 Medical Surgical Department
Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for
Taylor's Clinical Nursing Skills: A Nursing Process Approach, 3rd edition, by Pamela Lynn and Marilee
LeBon.
Scoring and Evaluation
Range Interpretation
21.25 – 28 .00 Excellent
14.5 – 21.24 Satisfactory
7.75 – 14.49 Fair
1.00 -7.74 Poor
For Major Examination:
Actual Score X 10 marks
Perfect Score